Essential Anatomy for oncoplastic surgery - Cairo … · Essential Anatomy for ... Surface anatomy 2. Surgical anatomy 3. Applied Anatomy. ... • The skin of the nipple contains

EssentialAnatomyforoncoplasticsurgery

OmarZ.YoussefM.D

Professorofsurgicaloncology

NCI-CairoUniversity

Introduction• RationaleforanatomicalbasisforOPS

• Anatomicalconsiderations:

1. Surfaceanatomy

2. Surgicalanatomy

3. AppliedAnatomy

ONCOPLASTICBREASTANATOMY

• BCS

• OPS:LevelI-IIoncoplasticsurgery(GR/TM)

• Contralateralbreastsymmetrization

• Skin(±NAC)sparingmastectomy

• Immediatereconstruction

– Implantbased

– Autologoustissuebased

IntroductionReconstructivePointofView

Anatomicalfeaturescriticalforoptimalresults:

• Qualityandtensionofskinflaps

• Preservationoftheinframammaryfoldframe

• Viabilityofnipple–areolacomplex(NAC)

• Integrityofthepectoralismuscle

• Qualityofabdominalandlatissimusflaps

• IfwelookatbreastsurgerycomplicationslikeNAC

necrosis,skinsloughing,woundcomplicationsand

fatnecrosis,wewillrealizethatitlargely

correspondstoanatomicalreasons

• That’swhyathoroughanatomicalunderstandingis

amust.

Surfaceanatomy

a) Langer’slines:

predominant

orientationof

collagenfibersin

theskin.Skin

creaselines

aroundthebreast

areessentially

circular

b)Kraissllines:

linesofmaximum

skinresting

tensionrunina

moretransverse

orientation

acrossthebreast

ONCOPLASTICBREASTANATOMY

ʺModifiedSweatGlandsʺ

NAC• Theepidermisofthenippleandareolaishighlypig-

mentedandsomewhatwrinkled.

• Theskinofthenipplecontainsnumeroussebaceousand

apocrinesweatglandsandrelativelylittlehair.

• The15to25milkductsenterthebaseofthenipple,

wheretheydilatetoformthemilksinuses.

• Thesesinusesterminateincone-shapedampullae.

• Thecircularareolasurroundsthenippleandvaries

between15and60mmindiameter.Itsskin

containslanugohair,sweatglands,sebaceous

glands,andMontgomery’sglands,whicharelarge,

modifiedsebaceousglandswithminiaturemilk

ductsthatopenintoMorgagni’stuberclesinthe

epidermisoftheareola

ONCOPLASTICBREASTANATOMY

SegmentalTDLUdistribution ↓

Oncologicalaspect

ONCOPLASTICBREASTANATOMY

“SuperficialFascia”

Existenceasadistinctlayer

56%

Inthosecontainingthislayer;

Complete 58%

Irregular/containsislandsofbreasttissue 42%

RobertsonSA,etal.BrJSurg2014.

Mainanatomicalfeaturesofthebreast

• Thefootprint

• Breastconus

• Skinenvelope

BreastFootprint

• Startingfromthepectoralistendon3to6cm

belowthesuperiormostpointoftheanterior

axillaryfold,extendingdownthelateralchest

wall

• Medially,theinframammaryfoldofthe

breastfootprintextendstowithin1to2cmof

thesternalmidline

• Curvinglaterallyatapoint7cmbelowthe

sternalnotch

• Superiorly,Thiscurvetapersintothelateral

partofthechestwallatapproximatelytwo

finger-breadthsbelowtheclaviclejustbefore

endingatitslateralborderbackattheaxillary

fold.

Skinenvelope

1. Quantityandquality

2. Redundantskinwillleadto

awkwardbreastshapesand

to(early)ptosis.

3. Skinshortageorover-

tighteningwillleadto

flatteningofthebreastand

woundhealingproblems

Conusofthebreast

SA=πr2+πrl

Anatomyofthebreast

ONCOPLASTICBREASTANATOMY

ONCOPLASTICBREASTANATOMY

ONCOPLASTICBREASTANATOMY

7-17mm

Dermis

Breast

Subcutaneousadiposetissue

RobertsonSA,etal.BrJSurg2014.

ONCOPLASTICBREASTANATOMY

Skinflaps

Ligamentsofthebreast

ONCOPLASTICBREASTANATOMY

“Wueringer’s

fibrousseptum”

Thinhorizontalseptumofdenseconnectivetissue

WueringerE,etal.PlastReconstrSurg101;1486,1998.

HorizontalSeptum

Originofhorizontalseptum

fromthoracicwallatthelevel

of5thribconnectswitha

ligamentoriginatingfrom

pectoralisfasciaatthesame

level,whichextendedintothe

IMF

ONCOPLASTICBREASTANATOMY

TowardsNipple-Areola

Coveredcraniallyandcaudally bytwodenselayersofarteries

Intraglandular:

•Cranially;thoracoacromialarterybranches

•Caudally;4th&5thintercotalarteries-cutaneousperforators

HorizontalSeptum

Atitsmedialandlateraledges,septumbecomesmoredenseandcurvesupwards; ligamentsattachingbreasttothoracicwall

ONCOPLASTICBREASTANATOMY

TowardsNipple-Areola

Subcutaneous:

•Medially;containsperforatingbranchesinternalthoracicarterytraversing2nd–4thintercotalspaces

•Laterally;containsbranchesofthelateralthoracicartery

TheinframmaryfoldIMF

IMF

• NomacrostructurefeaturingIMF

• Noanatomytextbookdescribedanyligament

• Highlydebated,relatedtotheories✰

Atrueinframammaryligament? THEORY

“Prepectoralligament”:itisnotatrueligamentbutratherthe

capsuleofaglandofectodermalorigin.Crescentshaped

ligamentbetweenskinandanteriorsurfaceofpectoralismajor

muscle

MaillardGF&GareyLJ.PlastReconstrSurg80;396,1987.

Subcutaneous,densefibrousstrandfollowingmarginofIMFand

extendsfromsternumtolateralmarginofpectoralismajorat

preaxillaryfold.

VanStraalenWR,etal.AnnPlastSurg35;237,1995.

“Inframammarycreaseligament”:condensationofrectus

abdominisfasciamediallyandfasciaoftheexternaloblique

andSerratusanteriorlaterally.Originatesmediallyfrom5th

ribperiosteumandlaterallyfromfasciabetween5thand6th

ribswhichinsertsintodeepdermisofIMF.

BayatiS&SeckelBR.PlastReconstrSurg95;501,1995.

Theinframammaryfold

skin

FasciaMammae

DeepfasciaScarpa

Cooper

“Condensationoftissuewithinthesuperficialfasciasystem”Fusionbetweenthesuperficialandmammaryfasciayieldstheinframammaryfold

INFRAMAMMARYFOLD

IMF• Nodemonstrableligamentousstructureof

denseregularconnectivetissue

• Nomammarytissue

• Onlyepidermis,dermis,superficialfascia,

adiposetissue

• Superficialanddeepfasciallayers

connectedtothedermis.

• MuntanCD,etal.PlastReconstrSurg105;549,2000.

IMF

MALES

NosuchorganizedconnectivetissuestructureintheregionofIMF.

MuntanCD,etal.PlastReconstrSurg105;549,2000.

BloodSupply

BloodSupplyofthebreast

Bloodsupply

NACBloodSupply

Mostconsistentisfrommedial(viainternalthoracicartery).

Alsosuppliedfromanteriorintercostalarteriesandlateralthoracicartery.

Veryrarelyfromdirectbranchesoftheaxillaryarteryorposteriorintercostal

arteries.

NACbloodsupply

Venousdrainage

• Thevenousdrainageofthebreastisdividedintoa

superficialsystemandadeepsystem.

1.Thesuperficialsystem:

• transverse(91%)andlongitudinal(9%)

2.Deepsystem:followsthearterialsupply

Venousdrainage

• Thesevenouspathwaysleadtothepulmonary

capillarynetworkandprovidearouteformetastasisto

thelungs.

• Thevertebralsystemofveinsprovidesanentirely

differentmetastaticroute.Theseveinsformavertebral

venousplexusandprovideadirectvenouspathwayfor

metastasestobonesofthespine,pelvis,femur,

shouldergirdle,humerus,andskull.

NerveSupply

NervesupplyINTERCOSTOBRACHIALNERVE

Lat.cutaneousbranchofT2intercostalnerve

Emergesfrom2thintercostalspace

Anastomoseswithcutaneousbrachiimedialis

nerve(branchofplexusbrachialis)

Suppliesskinonmed.&post.arm

90%fromT2alone

3% fromT3alone

7% fromacombinationofT2andT3

VARIATIONS

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ONCOPLASTICBREASTANATOMY

Conclusion

• Thoroughanatomicalknowledgeisamustto

performsafebreastsurgicalprocedures

• Respectinganatomicalguidelineswould

preventcomplicationsandimproveoutcome

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